HYPOTHYROIDISM IN PREGNACY:COMMON DILEMMAS, menopause , depresion , infertility, dyslipidemia, diabetes , CKD , women pregnancy

1. HYPOTHYROIDISM
IN PREGNACY:
COMMON DILEMMAS
DR. JYOTI BHASKER
DR. SHARDA JAIN
Dr. Jyoti Agarwal

2. Dr. Sharda Jain / Dr Jyoti Agarwal
Life Care Centre has a over 200 ppt on shildeshare.net
For benefit of Medical fraternity.
use it yourself & share among your friends

3. HYPOTHYROIDISM
Most common thyroid disorder in pregnancy
• Overt hypothyroidism : 0.3% to 0.5%
• Subclinical hypothyroidism : 2% to 7%
( In our clinical practise – 1 : 5)
• Anti TPO antibodies are present in 50% of SCH

4. Should women
routinely be screened
for thyroid disease?
YES !
• ALL WOMEN WHO ARE INFERTILE
• Planning Pregnancy, Rec. Miscarriage
• AT FIRST ANTENATAL VISIT OR AT TIME
OF DIAGNOSIS OF PREGNANCY

5. Morbidity Associated with Hypothyroidi
During Pregnancy:
• Spontaneous miscarriages
• Gestational hypertension and preeclampsia
• Premature delivery
• Increased frequency of neonatal ICU admissions
• Increased fetal mortality
• Impaired neuropsychological development

6. Joint Statement of AACE,
ATA and Endocrine Society:
Potential benefits of early detection and treatment
of thyroid dysfunction outweigh the potential side
effects that could result from early detection and
therapy…. Therefore, we favor screening for
subclinical thyroid dysfunction in adults, including
pregnant women and those contemplating
pregnancy.
Thyroid, January, 2005

7. What are the
Screening tests
to be done?
TSH
f T4 and anti TPO
IF HIGH ( Pregnancy specific levels)

8. THYROID PHYSIOLOGY
IN PREGNANCY
Increased oestrogen in
pregnancy
Two- to threefold
increase in TBG
Decrease Free T3
and T4
Similar structure of
hCG and TSH
hCG stimulates
release of T3 and T4
Transient TSH
decrease in weeks 8
to 14
Increased
peripheral
metabolism of T3
and T4
Decrease
Free T3 and T4

9. Thyroid hormone
changes during pregnancy
First trimester
Second
trimester
Third
trimester
TSH
Normal or
decreased
Normal Normal
Free T4 Normal Normal Normal
Free T3 Normal Normal Normal
Total T4 High High High
Total T3 High High High

10. TSH reference value
in pregnancy
Outcome-based recommendations suggest TSH:
• <2.5 in the first and second trimesters
• <3.0 in the third trimester.1,2
1. Marwaha RK, et al. BJOG. 2008;115(5):602-606.
2. Lazarus JH. Br Med Bull. 2010;1-12.

11. Anti TPO
• Over 50% of cases of SCH have anti TPO
• It is Positive only when levels are TWO times
the Normal
• Once positive – should not be repeated again.

12. Anti TPO
Significance :
1. It defines the cause as Autoimmune
2. It cautions for increased chances of PPT
3. Normal TSH with positive antibodies are
prone to become hypothyroid – Need
Monitoring

13. What is the management and appropriate
thyroid hormone replacement
in pregnant women?

14. Subclinical
hypothyroidism
• Elevated serum TSH and normal
FT4
• Biochemical thyroid hormone
deficiency

15. Subclinical
Hypothyroidism
• L-Thyroxine therapy for all pregnant women
with subclinical hypothyroidism
• Initiate dose according to TSH Levels
AIM: Step up and then Down
• Check TSH level and fT4 after 2-4weeks and
then TSH - 4-6 weeks or every trimester
• Dose to be reduced gradually after delivery
• Repeat TSH at 6 weeks postpartum

16. Overt
hypothyroidism
• Elevated serum TSH and
subnormal FT4
• Symptomatic thyroid hormone
deficiency

17. Overt Hypothyroidism
• Full replacement L-Thyroxine dosage:
– Pregnant women: 2.0 to 2.4 μg/kg of body weight
per day due to increased requirements
• L-Thyroxine treatment to be initiated at a dose of
100 to 150 μg/d
• Step Up and then Step Down
• Follow-up every 6-8 weeks, once TSH is normalised

18. HYPOTHYROID
ON
TREATMENT
• Estimate serum TSH and FT4
• Check their previous
investigations

19. Hypothyroidism
in pregnancy
• Preconception: Optimise therapy in patients with
pre-existing disease
Adjust T4 rx to serum TSH<2.0 prior to pregnancy
• Pregnancy confirmed: Increase dose by 30% to 50%
of preconception dose
• Target levels of TSH:
– <2.5 mIU/L in the first trimester
– <3 mIU/L in later pregnancy
1. Lazarus JH. Br Med Bull. 2010;1-12.

20. • After delivery: Reduce dose gradually to
preconception dose
• Assess thyroid function at 6 weeks postpartum

21. Thyroxin treatment for
hypothyroidism in pregnancy
TSH Average increment in L-Thyroxine dosage in women
without residual functional thyroid tissue depends on the
initial elevation of serum
1. The endocrine society website. http://www.endo-society.org/guidelines/final/upload/Clinical-Guideline-
Management-of-Thyroid-Dysfunction-during-Pregnancy-Postpartum.pdf. Accessed February 27, 2012.
Serum TSH elevation Augmented dose of L-
Thyroxine
5–10 mIU/L 25–50 mg/d
10 and 20 mIU/L 50–75 mg/d
>20 mIU/L 75–100 mg/d

22. EUTHYROID WITH ANTIBODIES
• No replacement with LT4 required
• No role of immunosuppressant
• Monitor the patient with TSH in every
trimester

23. Case study
• A 28-year-old lady with a history of primary
hypothyroidism presented with amenorrhoea for 6
weeks
• Past history: Diagnosed with hypothyroidism about 6
years ago and was started on L-Thyroxine
• She has been taking a stable dose of L-Thyroxine 75
µg/d for the past 2 years
• On examination: Diffuse and nontender enlargement
of thyroid gland was observed

24. Case study
• Laboratory investigations:
• Results of TFT
– TSH: 10.75 mU/L
– FT3: 5 pmol/L
– FT4: 12 pmol/L
• Urine pregnancy test: Positive
Diagnosis: Pregnancy at 6 weeks of gestation
with subclinical hypothyroidism

25. Question
What is the next step in the management of
hypothyroidism in this patient?
1.Maintain the same dose of L-Thyroxine
2.Increase the dose of L-Thyroxine
3.Terminate L-Thyroxine

26. Case study
• Thyroid function tests after 4 weeks:
– TSH: 2.4 mu/L
– FT3: 5 pmol/L
– FT4: 16 pmol/L
• Treatment:
– L-Thyroxine dose was maintained at 100 µg/d
• Advice: Follow up ?

27. Learning Activity
Women with hypothyroidism carry an increased risk of
A. Infertility
B. Miscarriage/spontaneous abortion
C. Maternal hypertension
D. All of the above

28. Pearls of Wisdom
Maternal Hypothyrodism is NOT
an indication for Termination of
Pregnancy
.

29. • Do not change brands
• It has to be taken empty stomach
• Keep it in cool, dry place, away from sunlight
• Minimum gap of 3-4 hrs between LT4 and Iron
and Calcium supplements
LT4 INTAKE

30. Endocrine Society, ATA, AACE
“Best Physician Practices” Guidelines:
• Patients should be maintained on the same
brand name l-thyroxine product
• Change from one brand to another, change
from a brand to a generic product, or change
from one generic to another generic requires
repeat TSH testing in 6-8 weeks
• Small differences in l-thyroxine doses may
have significant adverse clinical outcomes

31. BLOOD TESTS
• TSH CAN BE DONE AT ANYTIME OF THE DAY
• Among thyroid hormones , ask only for
FREE T4
• IF fT4 has to be done for monitoring, Sample
to be collected before taking tablets
• Only anti body to be tested – anti TPO

32. REMEMBER
• Screen all pregnant patients at very first visit
with TSH
• All women with infertility and who come for pre-
pregnancy counselling – Do TSH
• Target values : <2.5 in first trimester
< 3 in later pregnancy

33. Thanks

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